=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174811202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK AVE EYELAND EAST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2011
-----------------------------------------------------
Last Update Date | 03/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 E PARK AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11561-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-670-0700
-----------------------------------------------------
Fax | 516-442-3669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 E PARK AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11561-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-670-0700
-----------------------------------------------------
Fax | 516-442-3669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. LELAND BARRY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 516-670-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV004095-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------